CMS Changing Medicare Audit Process – Targeted Probe & Educate
Written by Editor   
Monday, August 21, 2017 05:56 PM

Medicare will be changing to a more focused approach to auditing physicians’ claims for payment.  Under the present audit system, the first round of claims reviews involve all providers for a specific service, so physician practices are randomly chosen for review.

In contrast, the new system will have the Medicare audit contractors (MACs) "select claims for items/services that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate. MACs will focus only on providers/suppliers who have the highest claim error rates or billing practices that vary significantly out from their peers,” CMS said on a webpage explaining the new system, which it is calling “Targeted Probe & Educate."

The program, which is currently being pilot-tested in four MAC jurisdictions, includes a three-part review and education process. 

In the first phase, 20-40 claims are reviewed, “followed by one-on-one, provider-specific, education to address any errors within the provider’s reviewed claims," according to the agency. “Providers/suppliers with moderate and high error rates in the first round of reviews will continue on to a second round of 20-40 reviews, followed by additional, provider specific, one-on-one education."

Providers and suppliers who still have high error rates after the second round "will continue to a third and final round of probe reviews and education," CMS said. "Providers and suppliers with continued high error rates after three rounds ... may be referred to CMS for additional action, which may include 100% prepay review, extrapolation, referral to a Recovery Auditor, or other action." Providers and suppliers who show improvement, on the other hand, "may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS."

The program gives providers two chances to correct things. First, there is the educational session and 45 days later, you get follow-up audit and it’s done, or if you're still an outlier, another attempt at education and another 45 days to correct the problem.